MEDICARE HOSPICE CRITERIA

1 MEDMEDMEDICARE HOSPICE CRITERIAICARE HOSPICE CRITERIAICARE HOSPICE CRITERIA (condensed for quick reference; final decisions require physician judgment and full LCDs) Need Part I OR (Part II + Part III) PART II .. Need A+B; C supports A. KPS or PPS < 70% ( <50% HIV; <40% stroke) B. Dependence on >1 ADL (bath, feed, dress, transfer, ambulate, continence) C. Comorbidities such as COPD, CHF, CAD, DM, Stroke, ALS, MS, Parkinson s, CKD, Liver, Cancer, AIDS, Dementia, Immune or Autoimmune, RA, SLE PART III .. Disease specific CRITERIA Cancer: Poor prog (small cell, pancreatic, brain) or Mets + decline despite tx or declines tx Alzheimer s Dementias: 1. FAST 7 = <7 words/visit + no consistent meaning to speech 2. Needs assistance for all ADL s (see Part II) 3. In the last year, one of: aspiration pneumonia, pyelonephritis, sepsis, stage 3-4 ulcer, fever post antibiotic, albumin < , wgt >10% Heart Disease: 1 + 2; 3 supports 1. Optimally treated or declines treatment 2.

2 NYHA Class IV (mostly bedbound, symptoms at rest) or EF < 20% in CHF 3. SVT/arrhythmias, hx resuscitation/arrest, hx unexplained syncope, cardiogenic stroke, HIV Liver: 1 + 2; 3 supports 1. INR > AND albumin < 2. One of: ascites, spontaneous bacterial peritonitis, hepatorenal syn, refractory encephalopathy, recurrent variceal bleeding despite therapy 3. Malnutrition, muscle wasting, alcoholism (> 80g/d), hepatocellular Ca, Hep Bs Ag+, refractory Hep C PART I .. General Decline = irreversible progression shown by A1. Clinical a. Recurrent infection: pneumonia, sepsis, pyelonephritis b. Inanition with one of: 1. weight loss > 10% in 6 months 2. arm circumference; abdominal girth; 3. clothes loose, skin turgor, skin folds 4. albumin or cholesterol 5. dysphagia + aspiration or oral intake A2. Symptoms Dyspnea + RR ; intractable cough; nausea/vomit despite tx; intractable diarrhea; pain + need major analgesia A3.

3 Signs BP to < 90 or postural hypotenson; ascites; venous, lymphatic or arterial obstruction; edema; pleural/pericardial effusions; weakness; LOC A4. Lab pCO2 , p02 or 02 sat ; Calcium, Cr, or Liver tests ; tumor markers ; Na or K or A5. KPS or PPS A6. FAST to 7a or below A7. Progression to dependence on >1 ADL (bath, feed, dress, transfer, ambulate, continence) A8. Stage 3-4 pressure ulcers despite care A9. medical visits for HOSPICE dx PART III .. Disease specific CRITERIA continued Pulmonary: 1 + 2; 3 supports 1a. Disabling SOB (fatigue, cough, bed to chair) or document FEV1 < 30% post tx and b. Increasing medical visits or declining FEV1 > 40 ml/yr 2. pO2 < 56 mm or sat <89% OR pCO2 > 49 mm 3. R CHF, wgt > 10% over 6 months, resting tachycardia > 100 Renal: 1 + 2; 3 supports 1. Dialysis stopped or needed and chosen against 2. One of : CrCl < 10 cc/min (< 15 CHF/;< 20 DM) OR Cr > mg/dl (> DM) OR in ARF: eGFR < 10 cc/min; OR in CKD: s/s of uremia: u/o < 400 cc/24 hr, K> w/ tx, uremic pericarditis, hepatorenal syn, fluid overload 3.

4 In ARF: comorbid vent, cancer, advanced lung/ CV / liver dz, AIDS, albumin < , Plt < 25, DIC, GI bleed; OR In CKD: eGFR <10 cc/min Stroke: 1 + 2 + 3 1. KPS/PPS < 40% 2. Cannot maintain adequate Intake 3. One of : wgt >10% in 6 months or in 3 months; albumin < , aspiration despite evaluation, calorie counts w/ inadequate intake, dysphagia w/o artificial hydration/nutrition Coma: 1; 2 - 4 supports 1. On day 3: three of: abn brainstem response, absent verbal, absent withdrawal to pain, Cr > 2. In last year: aspiration pneumonia, pyelonephritis, Stage 3-4 ulcers, fever post antibiotics 3. CT findings: Hemorrhagic: ventricular blood, > 20 cc infratentorial or > 50 cc supratentorial, > 30% surface area, midline shift > cm, obstructive hydrocephalus not treated by shunt 4. Thrombotic: large anterior with cortical and subcortical involvement; bihemispheric stroke; basilar or bilateral vertebral artery ALS: 1 + (2 or 3) + 4 and/or 5 supports 1.

5 Trajectory consistent with 6 months prognosis with muscle denervation widespread, no assisted ventilation 2. Impaired breathing + FVC < 40% predicted + 2 out of: SOB rest, orthopnea, accessory muscle use, abdominal breathing, RR > 20, reduced speech due to breathing, weak cough, sleep disordered breathing, PND or awakening due to breathing, somnolence, unexplained headaches, confusion, anxiety, nausea 3. 3 of the above symptoms (if cannot get FVC) 4. Impaired swallowing with dysphagia AND at least 5% wgt loss 5. Neurology opinion within 3 months of HOSPICE admission HIV/AIDS: 1 + 2; 3 supports 1. CD4 < 25 cells/ ml or viral load persists > 100,000/ml + 1 of: CNS lymphoma, > 10% wgt , cryptosporidium, progressive multifocal leukoencephalopathy, systemic lymphoma, visceral Kaposi s, renal failure, toxoplasmosis or MAC despite tx or refuses tx 2. KPS/PPS < 50% 3. Chronic diarrhea, albumin < , substance abuse, age > 50, refuses or resistance to HIV tx, AIDS, CHF, liver failure, toxoplasmosis despite tx